Select Specialty
Antibiotic Stewardship Program
We have been asked today to speak to our audience at our
LTAC hospital, Select Specialty, here in Nashville. I’m
David Jarvis, I do pulmonary and critical care medicine,
have been the medical director here in the Nashville LTAC
for 15-16 years.
I’m Julie Horton, an infectious disease physician who
practices at Select Specialty Hospital and am the Infectious
Disease Program Director at Select.
Dr. Jarvis: We began our Antibiotic Stewardship Program at
Select about nine or ten years ago. This was a time when it
became very well recognized in our medical community that
we were using more antibiotics than we needed to and the
excessive antibiotic use was leading to a significant
morbidity and mortality as well as increased costs. So, we
started looking at our own in house antibiotic usage to see
what we could do to sort of reign in the use of antibiotics. I
must say, when we started this, data drove what we were
doing. This LTAC hospital in Nashville is one of one
hundred and ten select LTACs in the country , so we have a
large data base with which to look and we started
comparing data from all our hospitals how much antibiotic
use was there at each hospital - and then ranking ourselves –
which hospitals had most antibiotic use, which had least,
and the ones that were more judicious in their use of
antibiotics, we asked them, “What are doing to do a better
job of using antibiotics than we’re doing?”
We meet at this same room, this same conference table.
There are twelve admitting physicians at this hospital: all
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pulmonary and critical care, and by getting together and
discussing this issue, we were able to come up with several
points that helped us decrease our antibiotic usage. Julie,
would you like to mention some of those “Pillars” of our
Antibiotic Stewardship Program?
Dr. Horton: Sure. As David mentioned at the start of our
program, a number of years ago, I think the genesis of it was
basically sitting around this table and discussing issues and
what we needed to do to be better. Clearly there was more
and more data emerging nationwide that antibiotic use was,
in most cases, excessive, and in many cases, unnecessary.
And, looking at that data and then examining our own
practices, lead us to make some changes. Obviously, there
were some national guidelines that helped us along the way,
and those are what we started with as what we described as
our “Pillars of Antibiotic Stewardship”.
The first one was looking at length of antibiotic duration in
selected patients. Putting automatic stop dates on antibiotic
usage was an easy fix once the physicians bought into it and
understood why we were doing it and realized why it was
appropriate in most cases.
The second one which took a little more discussion amongst
the physicians was really looking at appropriate
cultures/obtaining appropriate cultures and when to obtain
cultures. Because the patients at Select had been at other
facilities, often were colonized with bacteria from multiple
sites, it really took a lot of understanding to interpret the
cultures and say, ‘Maybe we don’t need to treat this positive
sputum culture in this patient that’s been mechanically
ventilated for the last two weeks. Let’s look at the whole
picture of this patient and decide whether this is appropriate
or not.’ And I think that’s a problem everywhere; that’s
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generalizable to many other facilities. Interpreting culture
data alone, outside of the whole clinical picture, it leads to
erroneous prescribing. We have to look at whether the
patient truly has an infection rather than just a positive
culture that is interpreted then as colonization.
We did a lot more cultures when we first started this project,
often on patients when they first arrived here just to see
what they had, and those cultures led to prescribing that
didn’t need to happen. And so it took all of us meeting all
together to say, ‘Maybe we should not do empiric culturing
or surveillance culturing in those patients and let’s wait see
what happens with the patient.’ Or, ‘If we have a positive
culture, let’s go back and look at everything before we make
a knee-jerk decision to prescribe antibiotics.’ And I think
that’s what’s led us to the great success that we’ve had so
far.
Dr. Jarvis: I certainly agree. What we find that physicians
do is treat cultures instead of the patient. And patients who
have been in the hospital for days or weeks at a time are
always colonized with bacteria. A sputum culture or a
tracheal secretion culture from someone who’s been in the
hospital for days or weeks at a time, really doesn’t tell what
the status is of the patient is because they’re almost always
positive. And, if we just keep treating those cultures, we just
keep treating patients that do not need to be treated. Now
that took some understanding amongst all of us physicians.
We discussed that as a group and we’ve done this almost
now ten years with great success.
Just to throw out some additional date, of the 110 LTAC
hospitals in Select, the Nashville hospital has the highest
case mix index. We see the sickest patients, by far: more
ventilator patients; more hemodialysis patients, so our
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patients are not well – they’re sick to begin with. But, in
spite of having the sickest patients of this large company
(110 hospitals), we have the lowest antibiotic use, the lowest
antibiotic cost, and, because of that, the lowest antibiotic cost
of the entire company. Now that wouldn’t work unless our
patients did well. So, we certainly look at how our patients
do. We have to compare ourselves to the other LTACs in
this company and nationwide, and we have much lower
than expected mortality rate and much higher than expected
ventilator wean rate. A significant number of our patients
actually recover and are able to go home as opposed to a
different level of care.
I think that we’ve shown over these last ten years that we
can lower our antibiotic use, have good outcomes, and lower
the cost of healthcare. We truly injure people by
overprescribing antibiotics. Dr. Horton has been our key
person in this. Several years ago we put together an
antibiotic ID group – ID physicians from around the country
- and came up with ‘pillars’ or suggestions for what we
could do to lower antibiotic use, not just here but throughout
the company. By taking those suggestions and emphasizing
that effort, Select has been able to decrease their antibiotic
use over these past three or four years by about 24%, which I
think is very striking.
Julie, there were a couple of other pillars, ‘IV to PO’ and the
‘Automatic Consultation’. Would you talk about those
things, as well?
Dr. Horton: Sure. The other things we instituted were the
‘IV to PO Conversion’ which, again I think was a relatively
easy institution as far as operationally the pharmacy is able
to do this and converts patients who are on IV medications
to an oral equivalent when that is appropriate.
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The final pillar that we have instituted – and this is still a
work in progress, I mean we still examine our data all of the
time – was having an automatic ID consultation for patients
that are on an extended length of therapy of antibiotics,
patients that are on more expensive antibiotic therapy, and
patients that are on more than one or two antibiotic agents.
So, there is a list of medications that a patient is admitted to
Select on those medications that I’ll get a call about and
review for the appropriateness of that data. And what I
found is quite interesting. Patients come from many other
facilities around the area. It takes quite a bit of leg work to
review what has happened to that patient during their
previous hospitalization. What I often find it may often
actually be sort of a random number that’s picked about
how much longer that patient needs to be on these three or
four or five antibiotics. I don’t think that there’s any
malintent on the part of the prescribing physician
previously, but they just want to make sure that the patient
is going to do “ok” and perhaps doesn’t know what
supervision the patient will get or perhaps who is going to
treat the patient. But, oftentimes, the antibiotic therapy has
really been adequate by the time they get here and more, in
this case, is not better. I think that’s often our comfort level
with antibiotics is so great that we think, “It’s ok to prescribe
another week or two of this medication because ‘what’s it
going to hurt’?” Well, we know from a lot of experience that
there’s harm that comes to the patient, both by toxic
reactions related to the antibiotic itself. Clostridium
Difficile, which is obviously a huge and growing problem,
re: alteration in the patient’s natural flora from being on the
antibiotics for so long. And then there is the harm that
comes to the community at large that we all live in that we
have seen an explosion of: antibiotic resistance, in part
related to our overprescribing of antibiotics. We’ve seen just
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in the last few years a marked increase in extended spectrum
betalactamases, for which we have very limited therapy and
those now are community associated. We are seeing those in
patients coming in from the community who’ve had very
little antibiotic exposure previously, so we know they’re
circulating in the community. And recently we’ve also seen
carbapenem-resistant organisms, fortunately, those are
relatively rare now, but unless we change our prescribing
habits and really reign in antibiotic use those are going to
become a major problem, in many cases, without any
antibiotic therapy, to treat those.
Dr. Jarvis: I’d like to emphasis again that Julie has been our
key person in this antibiotic program. I’d also like to
emphasize that, until we started this initiative nine or ten
years ago, we used antibiotics excessively, just like
everybody else did. When we looked at our data at all the
hospitals in the Select LTAC system, we actually used more
antibiotics than over half of the other hospitals. Now, with
the Antibiotic Stewardship Program, we’ve had the lowest
use of antibiotics year after year after year. So, emphasize
there that we have changed. What we did nine or ten years
ago and the way we treated patients is not what we do now.
And what we were doing then was doing more harm than
good because we were overtreating people with antibiotics.
But by getting physicians together, having educational
symposiums led by Dr. Horton, we were able to educate
ourselves that we were overusing antibiotics and there was a
better way. Doctors always want to do the right thing.
There has never been a doctor that has written an order that
didn’t think he wasn’t doing something for his patient.
Sometimes we just don’t know that we need to educate
ourselves and I think that’s what we’ve done here, with Dr.
Horton’s help. We just talked among ourselves that we
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don’t need to use antibiotics in all of these cases. For
example, just a hypothetical case, a typical patient we see, a
patient came into Vanderbilt or St. Thomas or Centennial
with septic shock. They ended up surviving
(hemodynamically stable) but they had ARDS on the ventilator,
they may have had acute renal failure, were going to require
dialysis for another three or four weeks before their kidneys
recovered. These patients live in the acute care hospitals for
two or three weeks before they come to us, they’re ‘trached’,
and those tracheal secretions almost always grow out some
organism that’s been colonized that is a colonization from
the acute care hospital. So, what we found in a lot of
hospitals is that those secretions will be repeatedly cultured,
they’ll be repeatedly positive. Maybe Klebsiella, maybe
Enterobacteriaceae, it could be anything. In the past, we’d
treat that culture just because it was positive. Physicians
have a reflex: if they see a positive culture, by golly, that
patient is going to get an antibiotic. But often that is exactly
the wrong thing to do because these patients are colonized
with all of these organisms but they’re not actively infected;
they don’t need therapy. So if we keep treating cultures and
we never sterilize the sputum or tracheal secretions, then we
keep people on antibiotics almost forever. And I think this
understanding and realization among the admitting
physicians that we don’t have to treat cultures, we have to
treat the patient and not just the cultures. What’s worked
well for us over these past ten years is that we’ve
dramatically reduced the number of cultures that we’ve
obtained. We do not feel that patients admitted to an LTAC
should be pancultured, we only obtain cultures when there
is a clinical indication. That would be temperature spike or
deterioration of the patient’s clinical status. Just obtaining
cultures to obtain them leads to bad care. That’s not only
true with tracheal secretions, it’s true with urine cultures, as
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well. I think as we all know, if a patient has a Foley catheter
in for more than just a few days, certainly by two or three
weeks, that culture is going to be positive for some
organism. That’s asymptomatic bacteruria and does not
need to be treated. If we treat that, then we get into the
problems to which Dr. Horton alluded, toxicity, C. diff, and
so forth. So it’s a new way of thinking about cultures, a new
way of thinking about patients. And we’ve been really
pleasantly pleased that we have had a sustained 75-80%
decrease in antibiotic use at this hospital over many years.
We feel that’s lead to many things certainly like lower costs,
less toxicity, and lower C. diff infection rates. There is one
new “Pillar” of Antibiotic Stewardship that we are now
discussing here that Dr. Horton presented to our group
yesterday and that would be the “Three Day Time Out and
Review of New Antibiotic Starts”. You might want to
mention that, Julie.
Dr. Horton: And, again, looking at the appropriateness of
antibiotics, a part of antibiotic stewardship is de-escalation.
Oftentimes patients are quite critically ill and in that
moment you are worried about them, you don’t know what
ultimately will be the cause of their infection, and the
appropriate thing is to treat broadly and to cover all of the
possibilities. So oftentimes, patients when they’re
deteriorating are started on multiple antibiotics while
cultures are being obtained, x-rays are being obtained, data
is being gathered, the appropriate thing to do thereafter is
review those cultures, and the next day or two or three, as
they become available, and sort of target their therapy as
what is appropriate, so they may not need Vancomycin, for
example., if they didn’t have MRSA. They might be able to
be de-escalated to a lower level of antibiotic therapy. And,
so this has been termed a ‘three day time-out’. Looking at
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reviewing all the culture data after a patient’s been started
on antibiotics at Day 2 or Day 3 when that data is available
and saying, ‘Well, maybe I don’t need to use meropenem,
maybe I can use Ancef instead.” Looking at whether they
actually need the two or three antibiotics that they were
started on, and, in some cases, they may not need those, it
may be a non- infectious cause of their deterioration. So, we
are in the process of instituting a formalized three day time
out review to look at that data to, in hope to pull out some of
the ongoing inappropriate prescribing.
Some of these later pillars become a little bit more difficult to
institute. The ‘Automatic Stop’ and the ‘IV to PO
Conversion’ are relatively easy to do for institutions who
haven’t started those yet, but for the ‘Three Day Time Out’,
it gets a little bit tougher. We’ve termed some of those ‘lowhanging fruit’ that are easier to take care of. It gets tougher
along the way but clearly this is the right thing to do and I
think there is still progress to be made in that regard.
Dr. Jarvis: I think that’s exactly right and what we’ve also
found is that the pharmacist needs to take a bigger role in
this arena. In the past, the physician – and currently, too –
the physician certainly is in charge in general of taking care
of the patient. Through the new medical era, one physician
cannot know everything there is to know about everything.
A lot of these drugs are very complicated now; they have
lots of side effects, so the pharmacist should be very much
involved with the antibiotic evaluation. It might be drug
interaction. The pharmacist – we’ve asked our pharmacist
at the end of 72 hours to track down the culture data and be
responsible for talking to Dr. Horton or one of us as the
attending physician just to say, “Here’s where we are, ” and,
if that even decreases antibiotic use by one day or two days,
that’s an advantage to the patient. We feel that some of the
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newer antibiotics – Cubicins, Tygacil – should be reserved
and used only in special occasions and only by ID doctors.
We don’t have many antibiotics in the pipeline. We’re
running out of tools to treat people with infection and we
need to preserve our best drugs for those patients who really
need them, and not just use them willy-nilly. That’s why at
this hospital we’ve made it automatic that an ID consultant,
Dr. Horton, will see every patient for whom these drugs are
prescribed. If they come into this hospital from another
hospital on these medications, Dr. Horton also gets involved
with those cases to make sure those drugs are indicated.
In looking at how data drives ‘best care’, no physician or
hospital knows how they’re doing unless we look and see
how we’re doing and then compare ourselves to how
everybody else is doing. Data is what drives medicine and
most doctors are data junkies. That’s how we make
decisions. We know that a drug works because studies have
shown that it works. So, it’s helpful for each hospital to look
at their antibiotic usage data and then compare it to other
similar hospitals, like all LTACs, all acute cares. And, if you
see that your hospital is using this much antibiotic, and
someone else is using this much, and the average is here,
then you have a problem. It’s not that “our patients are
‘sicker’”, or “our patients are ‘different’”, there’s a problem.
Variability of use of antibiotics is a problem. Variability in
medicine is a problem. A lot of hospitals get good results
using less resources and others use more resources and the
outcomes are the same. We need to be more cost-effective in
how we handle this.
In addition, I think what we’ve shown
here is that lower antibiotic use has led to better patient
outcomes than it did before we started this program. So, we
encourage all of our hospitals to show data to their medical
staff comparing what their antibiotic usage is compared to
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someone else. We also recommend that each physician be
looked at. Here in Nashville, we tack antibiotic use to each
physician and then we show that on a bar graph at our
monthly meetings. This is to let everybody know how
they’re doing. And again, no doctor has ever written an
antibiotic that he didn’t think was indicated, but sometimes
we all, including myself, write an order for a drug or an
antibiotic that maybe wasn’t indicated and it’s only by
looking at the data to see how we’re doing and comparing it
by someone else that we have a chance to make a change in
our own prescribing behavior. Data drives everything in
medicine.
Dr. Horton: So, we instituted this program approximately
ten years ago and made great strides initially, and continue
to make strides although at a bit slower pace given where
we are now. I think the sustainability of this has been one,
because our medical staff has been fairly constant in that
time. We’ve had some new physicians join us but who’ve
understood the way that we operate here at Select. I think
it’s been educational for them. So, they realize that…I’m
sure they take what they do here back to other hospitals
where they practice and utilize those practices there, as well.
I think it’s still a work in progress; we still monitor things.
The pharmacy is heavily involved as far as length of
antibiotics; they’re not afraid to pick up the phone and say,
‘Hey, do you know that so-in-so has been on Cefepine for
the last ten days? Tell me why you’re using this. Do we
need to get Julie Horton to come see the patient?’ So, I guess
maybe it’s the constant threat of my intervention. (laughter)
But I think, sitting around the table and looking at it, doctors
have had a real buy-in to it and realize that the outcomes are
good. A lot of it is a comfort level. It is a little bit scary
sometimes to say, ‘You know what? You don’t need to use
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three weeks of antibiotics for this problem. Really, the data
show that seven to ten days are enough. We don’t need to
do this ongoing.’ And that might be a little, in some ways,
scary for them to stop that. But once they see that they did
that, that patient did well, they can incorporate that into
their practice going forward.
Advice for peers getting started in this program: It is very
important. It can be difficult: it is a change. We don’t like
change; we like to do the same things we’ve always done
and in some ways it’s a little bit/ there’s a lot of uncertainty
to it. It is very worthwhile. It is very rewarding once you
see the results. And I think that what David emphasizes
often is it’s data-driven. Doctors want to see what the data is
and if you put numbers in front of them, which again, may
be hard institutionally to collect. It’s easy to say ‘to compare
your antibiotic usage to other facilities’ but, that data is
difficult to find out. I think that with some collaboratives
going on that data may be more available where we can
compare ourselves to others or compare ourselves to how
we’ve been doing and see that we’re making progress. But I
think that is a key to making changes. You can say all these
things, you can put them on a memo, but until you measure
them and follow them, you don’t know, you can’t see that
success that you’re having.
Dr. Jarvis: I think it’s important to emphasize the role of the
infectious disease doctor. The ID doctor is looked at by the
staff to make the right decisions regarding antibiotics. And
so the ID doctors have to buy-in to the realization that
antibiotic stewardship is important and provides better care
to the patient. We find a lot of variability in how the ID
doctors buy into that program. And so, it is very important
the ID doctors get on board with antibiotic stewardship, and
realize that treatment of colonization is rampant and needs
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to be reigned-in. But, without the buy-in of the infectious
disease doctor, it is unlikely that the program will work.
Often that’s about re-educating ourselves. As I mentioned,
up until about ten years ago, we were all using more
antibiotics than we need to and we thought we were doing
the right thing. Ten years ago was when we had our
epiphany, so-to-speak, that maybe we could do a better job.
And, I think it’s important for the infectious disease doctors
to look at their hospital, look at themselves and say, ‘Are we
doing everything we can to reign-in antibiotic use?’ And, to
look at data, as Julie mentioned, data drives everything, so
every hospital needs to compare how they’re doing with
everybody else and, if your numbers don’t look good, then
usually you’re doing something wrong and that can be
addressed.
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